Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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ST. MARY CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on February 25, 2020, it was determined that St Mary Center For Rehabilitation & Healthcenter was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Based on clinical record review and staff interview, the facility failed to ensure that showers were given to a resident as per his preferred and determined schedule for one of five sampled residents. (Resident CL1)

Findings include:

Clinical record review revealed that Resident CL1 was admitted to the facility on February 8, 2020, with diagnoses that included kidney failure, chronic kidney disease, diabetes, abnormal gait and muscle weakness. The Minimum Data Set assessment dated February 10, 2020, indicated that the resident was alert and oriented, required assistance of one person for bathing and that it was very important for him to choose his bathing option . Review of the care plan included an intervention for staff to assist the resident as needed with bathing and showering. Review of a nursing note dated February 13, 2020, revealed that the resident had clear speech and required assistance of one person for bathing. Review of the shower/bathing schedule for February 2020, revealed that the resident preferred showers twice weekly and was scheduled for a shower on Wednesdays and Saturdays. There was no documented evidence that the resident received a shower on Saturday February 15, 2020.

In an interview on February 25, 2020, at 12:10 p.m., the Director of Nursing confirmed that there was no documented evidence that the resident had received his shower as scheduled and preferred on February 15, 2020.

28 Pa.Code 201.29(j) Resident rights.

 Plan of Correction - To be completed: 03/18/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies. It is the practice of this facility to use the results of the assessment to develop, review and revise the residents' comprehensive plan of care.

1. Resident CL1 no longer resides at this facility.
2. No other residents were identified. An audit of current residents' charts will be conducted to determine if bathing had occurred per residents' schedules over the past seven (7) days.
3. Education will be conducted by the Staff Development Coordinator/designee with nurses and CNAs on providing showers/bathing per schedule; documentation of task provided or refused by residents; notifying nurse if resident refuses bathing, and nurse's responsibility to discuss choice with resident and offer alternate bathing episode if needed/requested.
4. Random weekly audits will be conducted by the Director of Nursing/designee to ensure bathing occurs per the residents' schedules. Audits will be conducted weekly for four (4) weeks, then monthly for two (2) months. Completed audits will be forwarded to the QA&A Committee for review and recommendation.
5. Date: March 18, 2020

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